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From the NICU to Primary Care: Improving the Quality of the Transition

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Care Transitions Sometimes called “handoffs” Movement of patients between health care practitioners and settings Shift changes ER to hospital OR to post-op or ICU ICU to floor One facility to another

Hospital to Home Prolonged time period during “handoff” Unclear lines of responsibility Lack of patient understanding of health care problems Lack of readiness for self-care responsibilities Lack of information for follow-up provider

What is a FMEA?“The technique involves identifying potential mistakes before they happen to determine whether the consequences of those mistakes would be tolerable or intolerable” Potential failures are identified in terms of failure “modes” For each mode the effect on the total system is studied.

Why FMEA? Powerful approach for proactive risk assessment Used in other high risk industries such as aerospace, aviation, nuclear industry

Our Project Perform a HFMEA for the transition in care from NICU to ambulatory follow up Use multiple methods to see if our predictions are correct Revise the HFMEA Develop a mitigation plan to address the identified risks

“Multiple Methods” to confirm the HFMEA Self-reporting of events (using TCH reporting system) Electronic triggers for possible adverse events ER visits within one month of discharge Readmissions within one month Missed appointments within one month Questionnaire for parents/caregivers the “Care Transitions Measure”

Retrospective Review • Charts reviewed using a trigger methodology to confirm or add to HFMEA findings (N=88) • Failures documented for 14 of 35 sub-steps predicted to have errors, in 1-10 cases each • Documentation in current medical records system inadequate to systematically collect reliable data • Documentation unavailable for majority of patients for 19 of the 35 sub-steps. • A pediatric-adapted “care transitions measure” developed and validated.

Qualitative Analysis of the HFMEA Process • The team members felt that the group functioned extremely well, with a high level of involvement and many new insights gained in the process. • The team encountered difficulty applying the HFMEA scoring system to the identified failure modes • The severity descriptions did not seem to fit the types of failure modes identified • Frequency descriptions did not seem sufficiently granular • The group modified both descriptions before it proceeded with scoring. • Some group members were concerned that scoring severity and frequency at the same time allowed for “gaming” of the scores • At the end of the process, the group scored one set of failure modes independently to determine whether this would significantly alter the scores (it did not).

Safe Passages • The final step of the HFMEA is the development of a mitigation plan • We addressed the three major themes that were identified in the HFMEA: • Lack of a standardized discharge plan • Inadequate parent/caregiver preparation • Lack of knowledge and skills by community-based health care providers

Safe Passages • We based the intervention on the Care Transitions Intervention (Coleman et. al.), adapted for a pediatric population. • Enhanced Personal Health Record • Health Coach • Just In Time Information for community-based health care providers

Enhanced Personal Health Record • Existing discharge plan is ad hoc • Existing standard discharge information limited to a single sheet of paper with diagnoses, medications and appointments written in by hand. • Note that for many of our babies, the paper chart weighs more than the baby.

Health Coach • A technically expert individual who takes the role of sensitive coach, teacher and facilitator to foster the development of parents into competent caregivers for their fragile infants. • Master’s prepared health educator, available at the hours parents are able to be present in the NICU. • Available to staff as a resource person

Just-in-Time information for primary care providers • Capitalized on new Evidence Based Guidelines program at Texas Children’s • One page summaries of evidence based guidelines for common problems • Transition from premature formula, oxygen weaning, growth of premature infants, management of gastrostomy, management of tracheostomy, chronic lung disease… and much, much more. • Sent home with infant and also faxed to provider at the time of discharge

Research Design • Concurrent Cohort Study over 1 year • NICU is divided into geographically distinct “pods” • One NICU III pod and its usual step-down Level II pod comprise the intervention group • Other pods comprise the control patients • IRB did not require patient/parent consent beyond verbal consent at the time of enrollment • But did require written consent for the evaluation of PCP compliance with JIT protocols

Progress to date • Recruitment of intervention babies is close to on-schedule (n~50 at 6 months) • Recruitment of control babies is behind (n~40) because 2 control units were closed for low census • Very few refusals to participate, very high rate of response to phone surveys • Moderate level of difficulty recruiting PCPs to the J-I-T intervention, so numbers are low.

Outcome Evaluation • Primary outcome is adverse events within 31 days of discharge (death, ER visit, readmission, missed appointments) • Care Transitions Measure – Neo: administered by phone 2-3 days after discharge and again at 31 days • Comfort level and satisfaction of PCPs with common post-NICU problems • Adherence to guidelines by PCPs